If you are an existing patient needing help, we have a few options for you.
1. Use our patient portal.
2. OR – Call us at 630-371-9980
3. OR – If you are having any difficulty with the phone system, please email at PatientHelp@painchicago.com
4. OR – fill out the following form:
Please complete pain diagram and bring to your appointment. If there are any Demographic/Insurance changes or HIPAA updates, please complete and bring to your appointment. Thank you.
Forms:
- Patient Demographics
- Signature Sheet
- HIPAA Form
- ARI Form
- Requisition for Forms – FMLA and Other
- Authorization for Release of Medical Records
(Please complete a request for form and fax it to our office at 630-371-1555. There is a 10 business day turnaround time) - New Patient Packet
- Request Medical Records
- Benefits Assignment Policy
- Interventional Procedure Instructions
- Credit Card Authorization Form
- Patient Agreement for Controlled Substances
- Release of Medical Records Form
Policies:
- Notice of Privacy Practices
- Opioid Policy
- Controlled Substance Agreement
- Opioid Consent for Treatment
- Controlled Substance Policy
Doctor Glaser is such an amazing person who I've had the fortune of being in his care great staff. Highly recommend you visit Chicago surgery
My mom, Joni turned 71 this past December and has suffered with horrible back problems for a majority of her adult life. This last year or so it got the worse it's ever been. She could no longer stand up straight, she was quite literally was walking at a 90° angle. It affected every aspect of her life from daily chores to breathing. She couldn't walk 15 feet without needing to rest and the pain was so excruciating it hurt me just having to watch. She couldn't even straighten up to hang up clothes. Dr. Glaser recommended she have something called the Minuteman procedure. He described the success he had seen in other patients and thought it would help my mom a lot. My mom was all for it, however, I was wary of her having any kind of surgical back procedure done. I went with her to one of her appointments and heard him describe the benefits. In the end we were both sold on the idea. Well, it's been 15 days and my mom is doing wonderful! It's truly a miracle. She no longer walks crippled over or even needs assistance from a cane. She's also gotten at least 70% pain relief. We don't have enough words to tell just how miraculous this procedure is. She was considering full back surgery. Instead she opted for the Minuteman. We are so, so grateful for Dr. Glaser and this brilliant little device. I personally can't thank Dr. Glaser enough for his knowledge and recommending the Minuteman to my mom. After seeing her suffer for so long it's amazing to see her walking up straight and confidently once again. Thank you more than words can say, Dr. Glaser, the staff at Palos Surgicenter, and Minuteman!!!
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